Transcription of Dr. David Salko for the show Pain, Addiction & Prevention #242
Lisa: Today, it is my great pleasure to talk with one of my colleagues at Central Maine Medical Center. This is Dr. David Salko, who is the Chief of Family Medicine at Central Maine Medical Center, the Medical Director of the Freeport Nursing Home, and also, the Coastal Primary Care Lead Provider. He and his wife Jen have four children and they live in Brunswick. You and I have known each other a long time, Dave.
Dave: Yes. I was pleased you said colleagues. You were one of my mentors.
Lisa: That’s a strong word, at least with one of your teachers at Maine Medical Center at the Family Practice Residency Program. My dad also is one of your teachers.
Dave: Your dad was a great guy. He’s the reason we selected the residency that we went to.
Lisa: They do a good job up there.
Dave: Yeah.
Lisa: You also have a family history of family medicine. You actually spent time practicing with your father in Pennsylvania.
Dave: After I completed my residency in Maine, I had the opportunity to work with my father. We did that for three years. I think it was really more like another fellowship. We’re doing hospitals. We were doing nursing homes. The only thing we didn’t do is deliver babies. I got exposure to a lot of medicine, and in I’ll call it an older way of caring that the practice of medicine is changed, that you don’t necessarily get the deep relationships that might have been there before. People selected their provider, their physician, their doctor to stay with them for the rest of their life. They didn’t move. Communities stayed the same and they relied on that person. I grew up in that. I was trained in it and I got to go back and work in it. That probably set me off to the direction that I am now in family medicine and why I love it as much as I do.
Lisa: You’ve been up in Topsham as a provider for how long now?
Dave: I think we’re going on seven years, seventh/eighth year. I came back to Maine in 2007 before our third child was born. We had a goal to have them all born in the state of Maine. The girls were born while we were in residency and then we had to high-tail it back to the state with my wife pregnant so we could have the third and fourth in the state. James was born 2007 and we moved just before that.
Lisa: You and wife your, Jen, both have a really strong commitment, both to family and to health. Jen actually does health coaching.
Dave: Yep. I think it’s around us. It’s something we use to help raise the kids with because we want them to have a good sense of their own health and their bodies. It’s something that we try to live. I think when you adopt something like that, the practice what you preach idea, it doesn’t so much feel like work as it feels like you’re helping other people, you’re coaching them along, you’re giving them information only so that they could improve themselves in a way.
Lisa: When I left private practice, I think I’ve told you this before, one of the reasons that I chose to go with Central Maine Medical Center and the practices in Topsham-Brunswick was because you were practicing there and you and I had interacted when you were a resident and I was a teacher. You always have this very caring way about you with patients, but also very intelligent. That’s a really important mixture in family medicine. I think family medicine is harder than people think.
Dave: It is. I think one of the statements I made recently, one of the talks or education sessions I gave was you have to listen to the music, not just the lyrics. I think it does take a special breed of person to listen to what the patient is saying, but also to watch them observe them and to understanding of the situation to really supply what they need. What they need may not be what they’re asking for and it really takes a relationship that you have to set up fairly quickly and a bond of trust with the patient that can then be very therapeutic for them. If they trust you, and you’re giving them good information, they can get better over time.
Lisa: This leads to something that I know you have an interest in or at least you’re willing to discuss.
Dave: Willingness, interest, sure. They all apply.
Lisa: Yeah. That is the issue of pain and addiction and medication for those issues. This has become an increasing problem over the course of, I think, both of our medical careers. It’s something that not every doctor feels completely comfortable with.
Dave: You know, I think everybody has a different, almost a sub-specialty within what they do, what they feel comfortable with, what they don’t. I always loved family medicine because of its breadth. There’s a lot of things that you need to know a little bit about. It might have been your dad who told me that. In being able to receive patients on any plane or any level that they come in with or any problem, you’ve got to at least know where to start.
As far as pain management and the use of opiates or other pain management things, that really has been evolving. It’s changed a lot since medical school. Pain was the fifth vital sign. It was we had to treat pain. We had to stop pain. There were pain scales. There were ratings on ERs, whether or not they controlled people’s pain. That was a very real thing that everybody had to step up to. People were given medicines the second they arrived in the emergency room so they weren’t in any pain. Pain was viewed as a bad thing. It really is a symptom just like a heart rate or anything else.
As we learn to live with it, from acute to chronic pain, that’s where a lot of things shifted. People did not want to live in pain. That’s reasonable and understandable, but as family physicians, we had to figure out a way to help people live healthy and live well, despite their chronic conditions, not just to bury them aside with a medicine that they can take to forget about it.
As we progress, I mean, nationwide, statewide, we know there’s an opiate problem. We know there’s an epidemic. We see the, not just the use, but the abuse of controlled prescription drugs just increasing astronomically. If we don’t educate the public, if we don’t educate our patients, if we don’t pay attention to that, it is going to get worse. That’s where I think a lot of the shift has been, both with state, national government, to kind of shift over the control there and shift over how we treat pain, how we deal with pain, and how we look at chronic pain as a diagnosis.
Lisa: There’s a lot of interplay between pain and emotional issues, between pain and depression, or pain and anxiety. Then it becomes complicated because there’s a whole other set of treatments for emotional issues. Sometimes you don’t know which has come first, the pain or the depression, for example.
Dave: That’s true. That’s where I’ll go back to that, “listen to the music rather than the lyrics.” Somebody can come in, tell you, “I’m in pain, I’m in pain, I’m in pain,” and really what they’re screaming out is that they’re depressed. That there’s something else about their life that they’re not happy with.
Now I think we’ve developed more of a broad approach where patients that will come and see me and talk about their pain, it’s very easy to say the statement like, “Well, we have a multidisciplinary approach now. Your pain is about more than just what you’re feeling for physical pain. We need to know that your life has taken on a new trajectory since that car accident twenty years ago or whatever happened that changed how your life has been going and we need to pay attention to that.”
The majority of people now are at least offered, if not go, for some co-counseling in the world of chronic pain. There’s specific psychologists and therapists that are developed around just dealing with living with chronic pain. That’s helped a lot, in a way. I think individual patients have been able to understand their pain, understand their bodies reaction to it, and then be able to make better choices as to how they’re treating it.
Lisa: I think the most complicated thing for many health care providers is that some of the medicines that we are using are physiologically addictive. You have your benzodiazepines that we’re using for anxiety, for example. Or you have your opiates that you’re using for pain. We, as health care providers, know that this addiction is possible. It’s a dependence. It’s not a judgment that I’m making that someone is addicted. It is a physiologic dependence upon these medications. How do you balance the need of the patient with something that maybe is, in the long term, is not the best medication for them?
Dave: I think you said it well right there. It’s really about letting the patient know that. That this may not be the best long-term solution. A lot more of what we do now, especially around controlled medications, is informed consent. “You’re going to take this. I’d like you to take it for two-three weeks. Yes, your body is going to get used to it. There may be some side effects when you stop it.” Helping people understand what their body is feeling and translating those feelings, physical or otherwise, into, “This is really an effect from the medicine.” When they understand that, I think they’re much more willing to be able to use or not use specific medicines.
It’s always a question of time. How much time do you have with a patient? How much time does it take to educate them through that? Some people that I see have come to me on those medicines and they’ve been on them for twenty years, longer. You really have to start somewhere. I think that’s where I sort of have this willingness to start wherever the patient is and make some progress in their health care by educating them, by telling them what they’re using, how it’s being used. We use a lot more handouts now. We can have a lot more resources, good internet resources. Things like that. Even specialists that people can go to that aren’t right there just to write another prescription. They’re there to figure out the mechanism of the pain and how people can get better.
I do often have that conversation with people of dependency versus addiction and tell them that, “Physically your body is dependent on this. Just like coffee, just like nicotine,” just like any other substance that they might understand and make a comparison. “Say you have three cups of coffee everyday and you stop drinking. What happens?” Everybody can recognize they get a headache from withdrawal.
Same things with their medicines. If they miss a dose, especially with an opiate, withdrawal can set in within 12, 24 hours. You can get body aches, physically feel tired, nausea, vomiting, diarrhea. There can be a lot of effects depending on the dose, but they can come really quickly. If people don’t recognize them for what they are, they might end up with a different outcome.
Lisa: Sleep is also really big when it comes to both pain and depression and actually anxiety. When people over the long term, for whatever reason, because they’re in pain or because they’re anxious, they’re not getting enough sleep, then it just becomes a vicious cycle. Unfortunately, some of the medications that we use for sleep also have been proven, over the long term, to not be that healthy for patients. It’s so delicate.
Dave: It is. A lot of the medicines, they have an effect and they also carry on side effects. One of the assessments that we’ll do for opiates, let’s say, and there’s a lot more screening and risk tools available to kind of evaluate people and have that conversation with what this med might do. People just want sleep, but the majority of your sleep meds just initiate sleep. They don’t actually prolong it or help it or make it more restful, refreshing. “Sleep is a habit,” I tell patients. I also tell them sleep is good medicine. If you can do that well, if you can set that habit well, you can start your day better. Your pain’s going to be better. A lot of different things. I think that’s a symptom of life, maybe, that your sleep becomes poor and then you’re days will follow with difficulty, you know?
Lisa: When I think about sleep medication, I think about the patients who often will tell me that even on the prescribed dose, the next day they feel hungover. It’s less likely that they can actually perform the jobs that they’re doing. I even worry a little bit about them driving. So often, what we’re told that we should prescribe as doctors is far more than what most people need. It’s something that we can really do on a fairly short-term basis just to break whatever cycle that is until they get into a better pattern.
Dave: That’s it exactly. To get into a better habit and they may need a trigger for awhile to reset that habit. What I’ve noticed over time, though, is we will often pull out the sledgehammer when we might need just a finer tool. Alternative medicine does provide us a lot of windows of opportunity. Acupuncture, aromatherapy, these might seem more subtle. Massage therapy. Things like that that could help institute a better cycle of sleep for people, a better restful state. Meditation. Those are all very, very, very powerful, but they take time. They take time for people to learn them. They take time for people to use them as a routine.
All those alternative things would apply as well to the management of pain. Everybody has an individual or subjective experience with pain, but we also have the ability with our mind to control how we feel in certain situations. Based on how we’ve lived, that’s the track record that’s set before us. That can be changed, it can be worked with, it can be altered. It’s just about creating a new loop, a new habit, a new experience.
Lisa: I find it really very encouraging that there are three of us in the Brunswick area who are physicians. You and Dr. Cindy Dechenes and myself, we all practice acupuncture and each of us have been doing acupuncture for a number of years. Having that kind of creeping into the medical mainstream, it makes me feel good because now we’re offering people something that might actually help their lives in a bigger way with, “Let’s just deal with the symptom.”
Dave: You know, ten or fifteen or twenty years ago, it might have been odd to even suggest acupuncture to a patient. Now it is more mainstream. We know how many people are using alternative medicines and alternative treatments. They do provide good relief and they do provide, I’ll say, individual success, even if there’s not some gigantic, ten-thousand-person study that says it’s going to work. We’ve seen a lot of individual success with that. It’s always good to offer people more options, more opportunities. If you limit yourself to one or two choices, you’re very unlikely to be successful over time with patients and that’s where the relationship with medicine goes. Somebody can come and see you and if you only have two options for headache, you’re going to be out pretty quick. You have to continue to go back and redefine the problem, redefine what successes they had, what failures they’ve had, and try to come up with new solutions.
I think the challenge of family medicine now is to integrate more of that, is to integrate more of the lifestyle, the things we hear about functional medicine, the things that we know about alternative treatments into people’s lives so they can have those good skills and have those good, I’ll call them self-adapting skills to be able to manage their problems.
Lisa: We’ve been talking about acupuncture, but there are also doctors who for a long time have been practicing what’s called osteopathic manipulative medicine, or manual medicine, in addition to chiropractors who are doing the same sort of manipulative medicine and often bringing together something like acupuncture with something like OMT or OMM manipulative medicine can be really life-changing, I think, for patients.
Dave: You’re right. When somebody has the opportunity or has a successful acupuncture, even OMT session, and they feel, even if it’s for a moment or a few days or a few weeks that their pain is more manageable or better, or that they’re able to do some of the things that they didn’t used to be able to do, or they can successfully do their job, take care of their kids, manage their life, that’s way more powerful than any pill will ever be. It’s not something they have to think about how to cope with. People who take a pill or something, it’s that moment they look for it to wipe everything away.
Whereas, if you’ve taught them a skill with meditation or they’ve been able to have OMT and some manual muscle therapies, they go, “Wow, I can do some of this myself.” They can actually correct some of the malalignments and the other problems that they’ve been carrying for years. They can be very useful for actually getting to the base of their problem, I think.
Lisa: Another, too, kind of foundational thing is that you and I both incorporate into our practices are discussion of diet and discussion of exercise. Because exercise, if you can get past an acute-pain flair, exercise over the long-term actually has been shown to be helpful for chronic pain issues for things like fibromyalgia.
Diet is also important. You referred to functional medicine and this is a very specific way of looking at nutrition in the life of a patient. We know that there are inflammatory foods that set off most patients and then, in addition, some people are sensitive to foods. Say citrus or wheat or dairy. How much do you bring this into your practice?
Dave: I think over a time as you develop a relationship with a patient, you’re going to be able to offer them a lot. I often think day one of the first person that comes in and I diagnose with diabetes, I think, “Wow, we can add five medicines today and sixteen quality goals to your list. We have all these things we have to do right now,” but it’s really a journey. Lifestyle definitely has to be part of their journey no matter what medication or medical problem they have, whether it’s pain, sleep, or something else.
That investment of what they can do, when they have control of the change, a lot of what we do now with motivational interviewing is to get people to seek out what it is they have control over, what it is they can change, little changes that they’ve noticed and help them build on them. Find those little bright spots where they say, “You know what? Last night I didn’t hurt.” “Why didn’t you hurt?” “Well, I didn’t eat all those French fries.” You know? I it can be as simple as that, but you can build off that and start to find any little lifestyle thing that you can pick up on.
I’ve had certainly patients come in and I really have not a great idea as to what’s going on, but I will always often tell them something along this line now and say, “There’s always a foundation of what we can do, okay? Good sleep, good nutrition, some exercise, and eliminate any real negative habits like smoking or alcohol.” Those are the fastest five things I can tell somebody that they can start with and it doesn’t matter what their problem is. You’re going to be able to impact the outcome based on their investment and their involvement in finding solutions through those means.
Lisa: I would add in something that’s not as quick, obviously, but that I think is also very important and part of the reason why I went into family medicine, I suspect you as well, and that is the importance of good relationships and understanding that if your primary relationship has some difficulties, that that’s actually going to impact your mood, your pain level, your ability to sleep. It’s a little bit harder to work through that sometimes.
Dave: It’s true. I think you need a good relationship with the patient. You need a good rapport with them for them to start to develop that trust in you to tell you those things. I think I’ve seen that a number of times over my career that someone will come in with a major life medical problem and you find out six months ago they went through a divorce or they had to move or they lost a job, some other big, stressful thing, and that will push them. It will push their body in a direction so that connection between their spirit or emotional state or mental state and their physical health is real.
It’s something that when they recognize it, I think they can make amendments to and they can change things, but it leads us in a way. If we can protect those relationships and we can nourish those relationships, they’ll come back and help us when we have a physical ailment to be able to support our bodies and support us staying in a realm of good health.
Lisa: One thing that I have thought a lot about, and probably because I have children like you, is the things that we offer to our children when they are younger to help them integrate with their lives as they get older. Some children do fine. Some children cope well with the world around them. Other children, maybe they have sensory issues or maybe they have some attention-deficit issues. This has become an increasing issue, autism, the autism spectrum. It’s an interesting and complicated thing that family doctors and pediatricians and other health care providers are dealing with.
Dave: Right. What kids have available now just in electronics, it may be a way for them to cope. It may be a way for them to have a nice tool. A lot of them have, I guess, a double edge to them. Is this something that is supporting the child or is this something that’s taking away?
Their ability to cope, too, I think a lot of times comes from those relationships that you mentioned. How good is their relationship with their care giver, family member, Mom, Dad, whoever’s around, siblings? They learn support from that. They learn how to be strong through difficult situations. They learn a lot of things from those relationships growing up and those are patterns. We know that we can track adverse childhood events now and say the more adverse childhood events that exist for a kid, the more difficulties they’ll have when they become grown up and to identify those and to get them to help and support, to get the emotional state settled, then they will be more successful.
Lisa: Dave, how can people find out about the work that you do at Central Maine Medical Center and your practice in Topsham?
Dave: Okay, they can call the office, I suppose. We have websites. I think there’s a Facebook site for Topsham Family Medicine. The office number is 798-6200. We are accepting new patients. We love working in that area. I love the job that I have and I really do enjoy the relationships I have with a lot of colleagues and people that I can share patient successes with and also to see people get healthier from a system base of care and a team base approach to care, rather than just an individual or a one-time prescription.
Lisa: We’ve been speaking with Dr. David Salko, who is the Chief of Family Medicine at Central Maine Medical Center and so much more. He and his wife, Jen, have four children and they live in Brunswick. Thank you so much for coming in today and thank you for being the person who brought me back into family medicine up in the mid-coast region.
Dave: I would just say thanks for the opportunity.